Birth Certificate Worksheet

Please note that the terms Birth Parent and Second Parent are used instead of Mother and Father because not all Birth Parents identify as mothers and not all Second Parents identify as fathers.

This terminology is consistent with New York state's instructions. On the Birth Certificate that you receive, the word Mother will be used for Birth Parent and either Father or Mother for second parent depending on who the Birth Parent is legally married to or acknowledges in the Acknowledgement of Paternity.

Birth Parent's Name (Birth Mother's Name) *

First NameMiddle NameLast NameSuffix

Birth Parent's Maiden Name (Last Name Given at Birth - Please enter even if same as current legal last name)

Birth Parent's Date of Birth (Birthing Mother)

Date

Birth Parent's City and State of Birth (Country if not USA)

Birth Parent's Legal State of Residence (Country if not USA)

Birth Parent's County of Residence (Territory or Providence if not USA)

Birth Parent's Locality - Call your city/town/village clerk's office at your city/town/village hall for this. Please do not guess. When you call, confirm you have the right hall by giving them your address.

If City or Village, Is Residence within City or Village Limits? If No, specify town in fill-in box, e.g. Town of _____. Please call your city/village/town clerk's office for the answer to this question. Do not guess as these boundaries can change.

YesNoI don't know: Call your Clerk's office as aboveOther

Birth Parent's Residence Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Parent's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is Medicaid a Secondary Payor for you Birth (secondary to other insurance you have)

YesNoI don't know

Are you Enrolled in an HMO through your insurance

YesNoI don't know

Birth Parent's Education Level

Birth Parent's Latinx/Hispanic/Spanish Origins

Birth Parent's Race (check as many as apply - the terminology is taken directly from the Birth Certificate form - if you prefer a different description, you may enter that in other)

Was Birth Parent Employed During this Pregnancy

YesNo

Birth Parent's Current/Most Recent Occupation (If you have been a stay at home parent without paid work, you may enter that here)

Birth Parent's Kind of Business or Industry, if not stay at home parent

Birth Parent's Name of Firm, if self-employed, you may write that if you don't have an entity

Birth Parent's Address of Firm, if self-employed and work from home, you may enter your home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Baby's Name (You may have more than one middle name and more than one last name. If you want a hyphenated last name, please include the hyphen.)

First NameMiddle NameLast NameSuffix

Baby's Date of Birth

Date

Locality of Birth if Different than Residence Locality (If you gave birth at a different residence than the one you listed above, please call the clerk's office for the residence where you gave birth to request the Locality for the Birth Location.)

County of Birth if Different than Residence

Is Birth Parent Legally Married? (Please note, by NY Law, no 2nd Parent can be listed on Birth Certificate if

Yes, legally married to Second ParentYes, legally married to someone other than Second ParentNo, but we will be submitting an Acknowledgement of PaternityNo and I will not submit an Acknowledgement of Paternity

If you Checked "legally married to someone other than second parent" and your legal spouse is male, by law your legal spouse must be entered on birth certificate. Fill out the following questions for your legal spouse even if they will not parent this baby.

Second Parent's Name (Legal Spouse or, if not married, Father of Baby if Acknowledgement of Paternity will be Signed. New York only allows a Second Mother on Birth Certificate if couple is legally married.)

First NameMiddle NameLast NameSuffix

Second Parent's Date of Birth

Date

Second Parent's City and State of Birth (Country if not USA)

Second Parent's/ Spouse's Education Level

Second Parent's Latinx/Hispanic/Spanish Origins

Second Parent's Race (check as many as apply - the terminology is taken directly from the Birth Certificate form - if you prefer a different description, you may enter that in other)

Second Parent's Current/Most Recent Occupation (If you have been a stay at home parent without paid work, you may enter that here)

Second Parent's Kind of Business or Industry

Second Parent's Name of Firm

Second Parent's Address of Firm

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

You're finished! Thank you for completing this form carefully. We take great care in filling out your baby's birth certificate and we appreciate your help completing this task.